PATOLOGIA OCULAR POR VIRUS HERPES

HERPES SIMPLE (VHS)

La gran mayora de las lesiones herpticas oculares estn producidas por el
VHS tipo I. El ndice de recurrencias a los 5 aos es del 40%. Las lceras
epiteliales responden al tratamiento antiviral, pero la afectacin estromal
puede no desaparecer por completo, dejando una cicatriz opaca o nefelin.
Las lesiones cutneas, en ausencia de una sobreinfeccin , curan sin
secuelas cicatriciales.
Conjuntivitis por el VHS
La afectacin ocular primaria por el VHS puede manifestarse como una
conjuntivitis o una queratoconjuntivitis folicular aguda con adenopata
preauricular y , a menudo, con la aparicin de vesculas en la piel
periauricular. Si no existen vesculas, el DD con una conjuntivitis adenoviral
se ve facilitado se tras la bsqueda cuidadosa se encuentran signos de
vesculas herpticas en el borde palpebral. A diferencia de la enfermedad
primaria, la blefaroconjuntivitis recurrente es una infeccin mucho ms
localizada. Las lesiones curan sin dejar lesiones cicatriciales. La conjuntivitis
suele ser difusa y se acompaa de secrecin serosa. Ocasionalmente la
tincin de Rosa de Bengala o de fluoresceina revela una lcera dendrtica
conjuntival. A diferencia de la multitud de pautas teraputicas empleadas
cuando la enfermedad herptica afecta a la crnea u otras estructuras
oculares, las manifestaciones herpticas limitadas a la conjuntiva requieren
un tratamiento sencillo. Los agentes antivirales o los esteroides no estn
indicados, sin embargo puede emplearse una pomada antibitica para
evitar una sobreinfeccin bacteriana. El seguimiento del paciente debe ser
estrecho para descartar la afectacin dela crnea o los anejos oculares que,
de producirse modificara el abordaje teraputico.
Queratitis primaria por VHS
Suele presentarse como una queratitis punteada difusa inespecfica que
evoluciona a la formacin de mltiples microdendritas dispersas por la
crnea. Estas lesiones pueden dar lugar a lceras serpinginosas lineales,
errticas, por toda la superficie corneal. El tratamiento indicado son
antivirales (aciclovir) de forma tpica, conjuntamente un un AINE tpico y
una pomada antibitica para prevenir la infeccin. En pacientes
inmunodeprimidos se puede combinar el tratamiento antiviral tpico con el
sistmico y mantener durante ms tiempo que el periodo indicado.
Queratitis recidivante por VHS
Brotes recidivantes de herpes ocular. Ulceras dendrticas ramificadas y finas
sobre el epitelio corneal. Los sntomas y signos caractersticos: epifora,
irritacin, fotofobia y en ocasiones, visin borrosa. En estos casos est
indicado la profilaxis antiviral por VO (aciclovir, famciclovir, valaciclovir).

HESPES ZOSTER OFTLMICO

Se trata de una reactivacin del virus varicela-zster. Es una
ganglioradiculoneuritis. De las tres divisiones del quinto par craneal, la
primera ( rama oftlmica) es con mucho la ms frecuentemente afectada.
( Inervacin de prpados, frente, punta de la nariz, mayor parte de la rbita
y anejos oculares). Es una infeccin muy agresiva y con un gran
componente inflamatorio.
El tratamiento es el que expusimos en la sesin, el uso de los corticoides
tpicos estara justificado porque disminuyen la respuesta inflamatoria y los
precipitados e infiltrados corneales. Siempre asociados a antivricos orales y
tpicos.

Tomado de: Enfermedades infecciosas. Principios y Prctica. Sexta Edicin.

2006. Mandell, Bennet y Dolin

Published 13 August 2009, doi:10.1136/bmj.b2624

Cite this as: BMJ 2009;339:b2624

Practice
10-Minute Consultation
Herpes zoster ophthalmicus
Fook Chang Lam, specialist registrar in ophthalmology1, Allison Law, general practitioner2, William
Wykes, consultant ophthalmologist1
1

Department of Ophthalmology, Southern General Hospital, Glasgow G51 4TF, 2 Southbank Surgery, 17-

19 Southbank Road, Kirkintilloch G66 1NH

Correspondence to: F C Lam fook_chang@hotmail.com
A 65 year old woman attends your practice with a two day history of a vesicular rash around her right eye.
She also reports a general feeling of fatigue and malaise and has been slightly feverish over the past week.
She had noticed a pain around her right eye even before the skin eruption began.

What issues you should cover

What is it and why has she got it?
After an attack of chickenpox the virus (varicella zoster) remains dormant in the body. This virus is kept in
check by the immune system. However, in 20% of people the virus is reactivated, resulting in a localised
painful rash with blisters (shingles). The commonest cause is a weakening of the immune system with age;

most patients are aged over 50 years. Other causes include stress, fatigue, and a weakening of the
immune system from other illnesses or from medical treatment (such as chemotherapy or
immunosuppression).
When the eruption involves the area around the eye (the ophthalmic or first division of the trigeminal
nerve), this is called herpes zoster ophthalmicus, irrespective of whether the actual eye itself is involved.
Ophthalmic herpes zoster accounts for 10-25% of all cases of shingles.
Have I got the right diagnosis?
The main differential diagnosis is herpes simplex infection. In herpes simplex the patients are usually
young, and the rash will not follow a dermatome, nor will it obey the midline. In herpes zoster
ophthalmicus it is not unusual for the oedema to track to the other side of the face, but the rash remains
dermatomal in distribution.
Can I predict who will get eye problems?
The appearance of the rash on the tip, the side, or the root of the nose indicates the involvement of the
nasociliary nerve (Hutchinsons sign) and a higher risk of ocular involvement (80%). Age, sex, and severity
of skin rash are not good predictors.
What are the possible ocular complications?
These usually develop from the second week after the onset of the rash. Post-herpetic neuralgia is by far
the commonest complication. Age is a potent risk factor. Antiviral drugs reduce the risk by 50%, but 20% of
affected patients aged over 50 will continue to report pain six months on despite initial antiviral treatment.
Less common complications are:

Lid complicationsptosis, trichiasis (ingrowing eyelashes), scarring of skin,

madarosis (loss of lashes), and

Anterior segment complicationsconjunctivitis, episcleritis, scleritis, stromal

keratitis (inflammation of the corneal stroma, which can lead to permanent
corneal scarring), neurotrophic keratitis (corneal degeneration caused by the
loss or reduction of corneal innervation), anterior uveitis (inflammation of the
anterior uveal tract), and raised intraocular pressure.

Rare complications include:

Posterior segment complicationsacute retinal necrosis (retinal viral infection

resulting in marked inflammation and retinal death), progressive outer retinal
necrosis (retinal viral infection in immunosuppressed patientsprogresses more
rapidly but eye is less inflamed), optic neuritis, and

Motor neuropathy, such as third nerve palsy.

Useful reading
Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect
Dis 2007;44(suppl 1):S1-26

Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med 2002;347:340-6, doi:10.1056/NEJMcp013211

Wareham DW, Breuer J. Herpes zoster (Clinical review). BMJ 2007;334:1211-15, doi:10.1136/bmj.39206.571042.AE

Useful information for patients

MedicineNet. Herpes viruses (including the chickenpox virus) and the eyes. www.medicinenet.com/herpes_of_the_eye/article.htm

eMedicineHealth. Shingles. www.emedicinehealth.com/shingles/article_em.htm

What you should do

Eye examination
Checking her visual acuity is vital. A normal vision and a "white" eye are very reassuring; however, be alert
to the Hutchinsons sign. Advise the patient to report any pain, reduced vision, or redness of the eyes, as
this indicates the need for a repeat assessment and more detailed eye examination.
Treatment and management
Oral antiviralsStart her on treatment with an antiviral (see box).

Antiviral treatment in herpes zoster

Systemic antiviral treatment shortens the healing process of acute herpes zoster and reduces pain and other acute and
chronic complications when given within 72 hours after onset of the rash.

Older patients shed the virus for longer and have a higher risk of complications and could still benefit from antivirals after this
period, especially if they still have new vesicles forming.

Antivirals should be considered in all patients with herpes zoster ophthalmicus, even if they are presenting after 72 hours.

Aciclovir, valaciclovir, and famciclovir are accepted in the United Kingdom as first line treatments. They are similar in tolerability
and safety, but aciclovir is usually the drug of choice on grounds of cost effectiveness. Some doctors prefer valaciclovir and
famciclovir because of the superior pharmacokinetics and more convenient dosing regimens.

Standard duration of treatment is 7-10 days.

Supplementary treatment with corticosteroids may shorten the degree and duration of acute zoster pain but has no effect on
the development of post-herpetic neuralgia.

AnalgesiaAntivirals, analgesics, and a neuroactive agent (such as amitriptyline, gabapentin, or

carbamazepine) are effective for acute pain and can be combined. Capsaicin cream to the skin is licensed
for post-herpetic neuralgia after the skin lesions have healed.
Bacterial superinfectionDiscourage scratching and tell her to keep the area clean with warm compresses
to reduce the risk of infection. Antihistamines relieve itching. Prescribe oral antibiotics if you suspect
superinfection.
IsolationAdvise her to avoid contact with individuals who have no history of chickenpox (especially
pregnant women) until the vesicles have dried up (usually after several days).
Referral
OphthalmologyA reduced visual acuity, a red eye (indicates inflammation), Hutchinsons sign, and
oculomotor palsy all warrant referral to ophthalmology. Because of the high risk of ocular complications,
patients with Hutchinsons sign should be seen within 1-2 weeks. Patients with a red eye should be seen
within 24 hours to 48 hours, while patients with a red eye and reduced vision should be seen the same day
or at the very latest the next morning.
Physicians and infectious diseases departmentMore severe disease, multiple dermatomal involvement,
or recurrence suggest an underlying immunodeficiency. Patients with organ transplants and patients on
systemic immunosuppression or chemotherapy need closer follow-up and should be managed in liaison
with a hospital physician. Extensive cellulitis will necessitate admission for intravenous antibiotics.
Pain clinicEstablished post-herpetic neuralgia can be very difficult to treat and can persist for years in
10% of patients with this condition. Neuralgia should therefore be treated aggressively. In more severe and
resistant cases the patient should be referred to a pain clinic before the pain becomes chronic and
established.
Cite this as: BMJ 2009;339:b2624

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes
contributions from GPs
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
(Accepted 19 March 2008)

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